Emanuel Péricles SalvadorI Alex Antonio FlorindoII Rodrigo Siqueira ReisIII,IV Evelyn Fabiana CostaII
I Programa de Pós-Graduação em Nutrição.
Faculdade de Saúde Pública. Universidade de São Paulo (USP). São Paulo, SP, Brasil
II Escola de Artes, Ciências e Humanidades.
USP. São Paulo, SP, Brasil
III Pontifícia Universidade Católica. Curitiba,
PR, Brasil
IV Universidade Federal do Paraná. Curitiba,
PR, Brasil Correspondence: Emanuel Péricles Salvador
R. Luiz Alberto Martins, 240, AP 24-A 05530-030 São Paulo, SP , Brasil E-mail: emanuelps@usp.br Received: 12/5/2008 Revised: 5/18/2009 Approved: 6/2/2009
Perception of the environment
and leisure-time physical
activity in the elderly
ABSTRACT
OBJECTIVE: To analyze the association between leisure-time physical activity and perception of the environment in the elderly.
METHODS: Cross-sectional study performed with 385 elderly individuals aged 60 years or older, living in the district of Ermelino Matarazzo, in the city of São Paulo, Southeastern Brazil, in 2007. The long version of the
International Physical Activity Questionnaire, in addition to speciic questions
for the study, was used to assess leisure-time physical activity. Assessment of the environment was performed using a perception scale adapted from the Neighborhood Environment Walkability Scale. For statistical analysis, multiple
logistic regression models were stratiied by sex and controlled by level of
education. The cut-off point of 150 minutes of physical activity per week was used to classify individuals who were active during leisure time.
RESULTS: The proportion of elderly individuals active during leisure time was 15.2% (19.1% and 12.5% for men and women, respectively). Presence of sports courts (OR=2.95), banks (OR=3.82) and health clinics (OR=3.60), good perception of safety during the day (OR=4.21) and invitation from friends
to exercise (OR=3.13) were associated with leisure-time physical activity in
men. Presence of churches or religious temples (OR=5.73), gyms (OR=2.49)
and squares (OR=3.63) were associated with leisure-time physical activity
in women.
CONCLUSIONS: Programs to promote physical activities for the elderly population must consider the variables associated with public and private
structures (gyms, squares, sports courts, health clinics and banks), places
where there are social gatherings (churches), social support (invitation from
friends to exercise) and perception of safety.
The practice of physical activities is one of the key strategies to prevent non-communicable chronic dise-ases such as osteoporosis, type 2 diabetes mellitus, arterial hypertension, coronary artery disease and obesity.a Physical activity enables the elderly to have
the opportunity for a more active and independent life, contributing to the maintenance of autonomy and better
quality of life.5 However, studies show that the
propor-tion of active elderly individuals is still low, especially during leisure time.11,20
Although several socio-demographic factors such as gender, age, income, level of education, smoking and
social support can inluence the practice of physical acti -vity in the elderly population during leisure time,6,13,23 these variables do not fully explain this practice.
Especially from the 1990s onwards, American, Australian and European studies have shown that the (natural, constructed and social) environment is associated with leisure-time physical activity in the elderly.2,8,10,14,16 However, in countries with average
income such as Brazil, there are no studies linking the perception of environment and this practice in the elderly population.
The present study aimed to analyze the association between the practice of leisure-time physical activities and perception of the environment in the elderly.
METHODS
A home-based cross-sectional study was performed with a representative sample of elderly individuals living in the district of Ermelino Matarazzo, in the city of São Paulo, Southeastern Brazil. This study was part of a broader research projectb on the inluence
of individual and environmental factors on the level of leisure-time and commuting physical activity, performed in 2007.
The district of Ermelino Matarazzo has approxima -tely 114,593 inhabitants and a population density of 12,807.85 inhabitants per km2. It is situated in the
eastern region of São Paulo, considered the most populated of this city.
According to the last census conducted by the Instituto
Brasileiro de Geograia e Estatística (IBGE – Brazilian Institute of Geography and Statistics) in 2000, Ermelino Matarazzo is comprised of 143 census tracts. The
INTRODUCTION
sampling process was performed by cluster in three stages: census tract (when 35 of the 143 census tracts available were selected), random selection of households in the census tracts selected (the number of households selected was proportional to the size of each census tract) and random selection of an elderly individual in the household selected.
To select individuals in the household, the Kish method15 was used, as it deines random tables according to the total number of residents. One table deined which
individual should be interviewed, based on the number of elderly residents in the household. A total of eight different tables were used so that the selections could maintain randomness. In this way, elderly residents in the households were ordered according to age, in a decreasing order (from oldest to youngest). Individuals selected should be older than 60 years of age and have
lived for at least six months at their address. Elderly
individuals who had diseases or problems that affected leisure-time physical activity in the week preceding the interview or who had mental disorders that prevented
them from answering the questionnaire by themselves were excluded from this study.
The following algebraic expression for the estimation of
proportions was used to calculate the sample size:15
Where:
- P: proportion of individuals to be estimated. Based on data from the City of São Paulo Health Survey, conducted in the city of São Paulo,7 the value of 0.15
was adopted as 85% of individuals were found not to have reached the recommendations of at least 150 minutes of leisure-time or commuting physical activity in this city;
- z= 1.96: value in the reduced normal curve
corres-ponding to the 95% conidence level;
- d= 0.065: sampling error allowed;
- deff=2.6: estimated design effect, based on City of São Paulo Health Survey data.
Thus, the minimum sample size was calculated to be 300 individuals.
n0
2
a World Health Organization. Integrated prevention of noncommunicable diseases: draft global strategy on diet, physical activity and health.
Geneva; 2003. (EB113/44 Add.1)
b Research “Atividade física e sua relação com o ambiente na população adulta do distrito de Ermelino Matarazzo da Zona Leste do
A total of 2,309 households were visited, of which 1,985 were successfully found. Out of 1,985 households,
1,455 did not have elderly residents. After exclusion of losses, refusals, and exclusions, the rate of response
was 72.6%. In the end, 385 elderly individuals were included in the study.
The long version of the International Physical Activity Questionnaire (IPAQ), used in the City of São Paulo Health Survey7 and whose validation and
reproducibi-lity have been described by Craig et al,4 was applied
to measure leisure-time physical activity. Questions about the following topics were added: types of mode-rate and vigorous physical activity practiced, place of main practice of (moderate and vigorous) physical activity, the form and length of transportation up to
the place of main practice, and the existence or not of
a physical education professional following the practice of physical activity.
Physically active individuals were considered to be those performing at least 150 minutes of leisure-time physical activity per week; less than ten minutes per week meant the individual was considered inactive; and those who performed at least ten minutes, but less than 150 minutes
per week, were considered insuficiently active.
The Brazilian version of the Neighborhood Environment Walkability Scale21 (NEWS), validated by Malavasi et
al,18 was used to assess the perception of environment.
This scale underwent changes for better understanding
by elderly individuals studied. The adapted inal version
of NEWS was discussed by specialists from the
envi-ronmental and physical activity ields and comprised of 38 questions. The irst part of the questionnaire was
structured so that individuals answered how long it would take them to walk from their homes to different business, service or leisure locations in the district
where they lived (parks, squares, places for walking, gyms, clubs, sports courts, soccer ields, bus stops,
train stations, health clinics, drugstores, churches or religious temples, bakeries, banks, bars, free markets, grocery stores, markets and supermarkets). The second
part of the questionnaire was comprised of questions
about the environmental structures close to the elderly
individuals’ homes, such as the presence and quality
of sidewalks and green areas; whether the streets were
lat or not; places where there was piled-up garbage and open-air sewage near homes; whether or not trafic made it dificult to walk or ride a bicycle; whether or
not there were crosswalks near homes; whether or not drivers usually respected pedestrians on crosswalks; whether or not there was pollution caused by smoke near homes; whether or not the streets close to homes were well-lit at night; whether or not elderly individuals considered it safe to walk around their homes during the day and at night; whether or not they received invita-tions from friends, neighbors or relatives to walk, ride
a bicycle or exercise in the neighborhood; whether or not the (cold, rainy or hot) weather made it dificult to walk, ride a bicycle or exercise in the neighborhood;
and whether or not they had a dog and walked their dog. Elderly individuals were instructed to consider places they could reach in up to ten minutes on foot as close to their homes.
The modiied scale from the original NEWS and the
majority of responses were standardized as dichotomic scales based on pre-tests conducted before collection and involving discussions with researchers. However, no validation and reproducibility processes were performed.
All study variables were analyzed in a descriptive way
using absolute and relative frequency, for women and
men separately. The χ2 test was performed to verify
possible differences among levels of leisure-time
physical activity, according to sex.
Bivariate regression analyses were conducted between leisure-time physical activities (dependent variable) and environmental variables (independent variables). Associations that showed p<0.20 were selected to prepare the multiple model.
Independent variables were organized in an increasing
order, according to the level of signiicance, and the
forward selection strategy was used in the model cons-truction to create multiple logistic regression models, where each dependent variable was individually added and its permanence in or removal from the models
depended on its statistical signiicance. The variable
level of education was used as adjustment and added
to the inal model.
Sampling weights (complex sample) were used and
all analyses were made with the SPSS software, version 15.0.
The study was approved by the Research Ethics Committee of Faculdade de Saúde Pública da USP (São Paulo University School of Public Health). All participants who performed a physical assessment
received explanatory materials on preventive tests; guidance on Alzheimer’s disease, quality of sleep,
practice of physical activity and most suitable places
to exercise; guidance on a healthy diet; and a booklet
on elderly rights.
RESULTS
Both sexes showed proportions lower than 20% of active
individuals during leisure time, with men showing a higher proportion of physically active individuals in relation to women (p<0.041). Women showed a higher proportion (72.5% vs. 64.5%) of physically inactive
individuals (p<0.05). As regards the proportion of people
classiied as insuficiently active, there was no signii -cant difference between women and men (Table 1).
Of all elderly individuals classiied as physically active
during leisure time, 87.7% of men and 63% of women practiced walking, followed by general gymnastics, Tai Chi and cycling (Figure).
Of all the 38 environmental variables, 13 were selected (p<0.2) for the analysis of multiple logistic regression
in both sexes (Table 2).
Among men, six variables remained in the multiple
model: good perception of safety during the day, presence of sports courts, length of walk to a health clinic of up to ten minutes, invitation from friends to
exercise and presence of gyms close to home. After
inclusion of the “level of education” variable, elderly individuals who had a good perception of safety during the day were four times more likely to be active during leisure time; those who had a sports court close to home were three times more likely to be active during leisure time; those who lived less than a ten-minute walk from
a bank were ive times more likely to be active during
leisure time; those who lived less than a ten-minute walk from a health clinic were four times more likely to be active during leisure time and those who were
invited by friends to exercise were three times more
likely to be active during leisure time (Table 3). Among women, three variables remained in the model: walks of up to ten minutes to a church or religious
temple, presence of squares and presence of gyms.
After inclusion of the “level of education” variable, elderly women who lived less than a ten-minute walk
from a church or religious temple were almost six
times more likely to be active during leisure time; those
who lived near squares were four times more likely to
be active during leisure time; and those who lived near gyms were two times more likely to be active during leisure time (Table 4).
DISCUSSION
There are few studies on this topic in the international literature and none in Brazil. The present study was the
irst to verify the association between environmental
variables and leisure-time physical activity in elderly Brazilians.
Good perception of safety, presence of squares and
gyms, living less than a ten-minute walk from a bank
or health clinic and being invited by friends to exercise
were associated with leisure-time physical activity in men, whereas living less than a ten-minute walk from
a church and the presence of squares and gyms were
associated with physical activity in women.
The proportion of active elderly individuals during leisure time found in the present study differs from
Table 1. Classification of levels of leisure-time physical activity in the elderly population. Municipality of São Paulo, Southeastern Brazil, 2007.
Leisure- time physical activity
Men Women Total
n % 95% CI n % 95% CI n % 95% CI
Inactivea 100 64.6 55.1;73.0 169 72.5 63.1;80.2 269 69.3 62.2;77.5 Insufficiently activeb 23 16.3 10.6;24.2 37 15.0 11.0;20.3 60 15.6 12.2;19.8 Activec 29 19.1 12.2;28.8 27 12.5 7.1;20.9 56 15.1 10.1;22.2
Total 152 100.0 233 100.0 385 100.0
a Less than 10 minutes of physical activity a week. b Between 10 and 149 minutes of physical activity a week. c150 minutes or more of physical activity a week.
90 80 70 60 50 40 30 20 10 0
Walking
Gener
al gymnasticsHydrother apy
CyclingTai Chi
Resistance tr aining
Walking on treadmill
HandballRunningSwimmingOthers
Men Women %
other national results. Monteiro et al,19 while analyzing
1,810 elderly individuals living in Southeastern and Northeastern Brazil and considering 150 minutes of physical activity per week as the criterion to classify those physically active, found proportions of only 7.3% and 6.3% of physically active individuals in men and women, respectively, nearly half the values found in the present study. On the other hand, Zaitune et al,26 in a study performed (N= 426) in the city of
Campinas, Southeastern Brazil, found a proportion of elderly individuals practicing leisure-time physical activity of 29.3%. Although the value is higher than that found in the present study, authors did not adopt the criterion of 150 minutes of physical activity per
week as the cut-off point for classiication. Florindo et
al6 studied 326 men in the greater São Paulo area, aged
50 years or older, and found a prevalence of 6.1% for
any type of practice, frequency and time of physical
activity in the last 12 months.
The type of physical activity most practiced by the
elderly individuals in the present study in both sexes
was walking, followed by general gymnastics, cycling and Tai Chi. This result was similar to that found by Monteiro et al19 and walking was the activity most
practiced by elderly men (84.6%) and women (80.0%). Hughes et al,11 in a recent study published
in the United States with a sample of 5,589 elderly individuals, showed that 34% of those who were active practiced walking during leisure time and this was the
irst physical activity option of this sample.
Table 2. Association between variables of perception of environment and recommended practice of physical activity during leisure time in the elderly. Municipality of São Paulo, Southeastern Brazil, 2007.
Environmental variables OR 95% CI p
Men*
Safety during the day 3.56 1.54;2.86 0.004
Presence of sports courts 2.27 1.07;4.85 0.035
Length of walk to a banka 2.83 1.07;7.46 0.037
Walking a pet dog 2.60 0.98;6.89 0.055
Length of walk to a health clinica 2.01 0.98;4.11 0.056
Presence of soccer fields 2.31 0.92;5.84 0.074
Invitation from friends to exercise 2.88 0.83;10.04 0.094
Presence of gyms 1.82 0.88;3.76 0.104
Length of walk to a gym* 1.82 0.87;3.80 0.110
Length of walk to a place suitable for walking* 1.98 0.84;4.64 0.114
Presence of crosswalks 1.82 0.78;4.24 0.160
Presence of grocery stores 3.02 0.62;14.70 0.165
Invitation from relatives to exercise 2.35 0.66;8.36 0.182 Women*
Length of walk to a churcha 6.08 1.53;24.16 0.012
Presence of squares 4.28 1.39;13.19 0.013
Presence of gym 2.51 1.18;5.35 0.018
Drivers respect crosswalks 10.04 1.30;77.32 0.028
Length of walk to a banka 3.35 1.10;10.14 0.034
Length of walk to a grocery storea 2.48 0.86;7.15 0.089
Presence of green areas 2.09 0.88;4.97 0.094
Length of walk to a bara 2.72 0.78;9.48 0.114
Length of walk to a squarea 2.10 0.73;6.02 0.161
Presence of bars 2.67 0.64;11.12 0.170
Length of walk to a free marketa 3.10 0.58;16.49 0.177
Length of walk to a gyma 1.83 0.73;4.54 0.188
Presence of flat streets 3.03 0.57;16.18 0.188
* p<0.20
Table 4. Final multiple logistic regression model of recommended practice of leisure-time physical activity in elderly women. Municipality of São Paulo, Southeastern Brazil, 2007. (n=233)
Variable Multiple model Final model
a OR 95% CI p OR 95% CI p Length of walk to a church or religious temple of up to
ten minutes 7.78 1.98;30.67 0.005 5.73 1.43;22.90 0.015 Presence of squares 5.41 2.11;13.83 0.001 3.63 1.33;9.88 0.013 Presence of gyms 3.66 1.45;9.20 0.007 2.49 1.10;5.62 0.029 a Adjusted for level of education
Good perception of safety associated with leisure-time physical activity was found in different international studies. Guiles-Corti & Donovan9 found a signiicant
association between good perception of safety and recommended level of leisure-time physical activity in 1,803 Australian adults (OR=1.49, 95% CI: 1.14;1.95). Boehmer et al2 observed that Americans who reported
not feeling safe near their homes were 191% more likely to be inactive during leisure time than those who reported feeling safe near their homes (OR=2.91, 95% CI: 1.86;4.55). Although both studies showed a significant association between good perception of safety and leisure-time physical activity, they had adults and elderly individuals analyzed together as part of the sample. Only the study published by Lim & Taylor17 (2005) analyzed elderly individuals exclusively
(n=8,881) and, differently from the present study, there
was no signiicant association between good perception
of safety and the recommended levels of leisure-time physical activity (OR=0.94, 95% CI: 0.85;1.03). In the case of the district of Ermelino Matarazzo, an area
involving social and structural inequalities, safety
becomes a relevant factor for any tasks performed by elderly individuals, including the practice of leisure-time physical activities.
A total of four environmental structures constructed showed positive association with leisure-time physical activity in men: presence of sports courts and gyms in the district, walking for up to ten minutes to a health clinic and bank. Sports courts, gyms and health clinics
are suitable structures for the practice of leisure-time physical activity. Certain basic health units promote physical activity programs for users. In a study performed by Sallis et al,22 it was observed that
indivi-duals who lived in districts with greater availability of places suitable for physical activity had a better chance of being involved with the practice of physical activities more than three times a week. Brownson et al3 analyzed
1,818 adult and elderly Americans and showed that those who reported the presence of gyms in their district were 94% (OR=1.94, 95% CI: 1.45;2.60) more likely to be physically active during leisure time.
Huston et al12 studied 1,796 adults and elderly
indi-viduals from seven different American cities and concluded that having access to places for physical activity such as parks, clubs and gyms around their homes or even in the workplace, schools, and commu-nity centers outside the district increased their chances of performing some type of leisure-time physical acti-vity (OR=2.23, 95% CI:1.44;3.44) and achieving the recommendations of 150 minutes of moderate physical activity or 60 minutes of vigorous leisure-time physical activity (OR=2.15, 95% CI:1.23;3.77), compared to those who did not have the same access.
In contrast, while analyzing 1,209 adults and elderly individuals, Garcia Bengoechea et al8 showed that men
who agreed with the following statement, “I have easy
access to places where I can exercise”, were more likely
to be physically active during leisure time (OR=1.82, 95% CI:1.00;3.31).
Table 3. Final multiple logistic regression model of recommended practice of leisure-time physical activity in elderly men. Municipality of São Paulo, Southeastern Brazil, 2007.(n=152)
Variable Multiple model Final model
a OR 95% CI p OR 95% CI p Good perception of safety during the day 4.51 1.26;16.15 0.022 4.21 1.29;13.79 0.019 Presence of sports courts 3.00 1.23;7.29 0.017 2.95 1.23;7.09 0.017
As regards banks, the present study assessed this structure in an individual way, differently from other studies, where banks were assessed as part of a set of other variables that can be associated with aspects that promote the practice of physical activity in the elderly. In this sense, the result of the present study could be an
indication that close proximity to business and service
structures, such as banks, can facilitate elderly indivi-duals’ routine tasks, in addition to its being associated with the presence of other aspects that promote the practice of leisure-time physical activities.
As for the inluence of churches or religious temples
on physical activity, only two studies by Wilbur et al24,25 conducted this type of analysis and did not ind signiicant results. In the case of the district of Ermelino
Matarazzo, elderly women involved with religious activities were probably more likely to be active as they participated in activities developed in the religious institutions themselves, especially with the organization in groups.
The “invitation from friends to exercise” variable was
significantly associated with leisure-time physical activity in men, a result similar to that found by Ball et al1 in 3,392 adult and elderly Australians. Individuals who did not have company to exercise were 31% less
likely to walk during leisure time.1
In terms of study limitations, the cross-sectional design does not enable the establishment of a relationship of
cause and effect, once the community environment
may undergo constant changes that can inluence both
the perception of the environment and the association with physical activity in the elderly.
As regards the instrument to assess physical activity,
only questions about the length of practice of
leisure-time physical activity, leisure-time of practice and follow-up by a physical education professional were added,
without modiications to the original questions of the
long version of the IPAQ used in São Paulo.7 Thus, this change does not interfere in the quality of information
associated with the total amount of physical activity practiced. In addition, the choice for the long version
of the IPAQ is justiied in that the study was interested in assessing different contexts of physical activity sepa -rately (commuting, leisure time, household and occupa-tional), an analysis that would not have been possible if the short version of the instrument had been used. In conclusion, the present study showed that the set of
speciic structures of the community environment –
such as the presence of churches or religious temples,
squares, gyms, banks or basic health units, in addition
to a good perception of safety and invitation from
friends to exercise – are associated with the practice of
leisure-time physical activity and must be considered when planning programs to promote physical activities for the elderly population.
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